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Health Care System Reform and the Nursing Workforce: Matching Nursing Practice and Skills to Future Needs, Not Past Demands1

Julie Sochalski, Ph.D., R.N., FAAN

University of Pennsylvania School of Nursing

Jonathan Weiner, Dr.P.H.

Johns Hopkins University Bloomberg School of Public Health

INTRODUCTION

The Robert Wood Johnson Foundation’s Initiative on the Future of Nursing is founded on a major study, undertaken in collaboration with the Institute of Medicine, that will “examine the capacity of the nursing workforce to meet the demands of a reformed health care and public health system.” A report pursuing such a goal is propitious, and path-breaking from the legion of nursing workforce reports produced over the past half-century by departing from “what is” and focusing on “what should be.” This paper seeks to aid that effort through a detailed examination of how health reform may alter the demand for the registered nurses (RN), and the degree to which the RN workforce measures up to this anticipated demand.

A thoughtful examination of the capacity of the RN workforce to support health reform is important for several reasons. The health reform legislation signed by President Obama on March 23, 2010, and the American Recovery and Reinvestment Act of 2009 which proceeded it, include a range of initiatives that seek to redesign the organization, financing, and delivery of health care. A number of these programs—for example, primary care medical homes and accountable care organizations (ACOs)—rely on interventions that fall squarely within the scope of practice of RNs (e.g., care coordination, transitional care). Furthermore, expanding the reach of insurance coverage will place greater demands on the primary care system, as witnessed in Massachusetts (Long, 2008; Long and

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F
Health Care System Reform and
the Nursing Workforce: Matching
Nursing Practice and Skills to Future
Needs, Not Past Demands1
Julie Sochalski, Ph.D., R.N., FAAN
University of Pennsylvania School of Nursing
Jonathan Weiner, Dr.P.H.
Johns Hopkins University Bloomberg School of Public Health
INTRODUCTION
The Robert Wood Johnson Foundation’s Initiative on the Future of Nursing
is founded on a major study, undertaken in collaboration with the Institute of
Medicine, that will “examine the capacity of the nursing workforce to meet the
demands of a reformed health care and public health system.” A report pursuing
such a goal is propitious, and path-breaking from the legion of nursing workforce
reports produced over the past half-century by departing from “what is” and fo-
cusing on “what should be.” This paper seeks to aid that effort through a detailed
examination of how health reform may alter the demand for the registered nurses
(RN), and the degree to which the RN workforce measures up to this anticipated
demand.
A thoughtful examination of the capacity of the RN workforce to support
health reform is important for several reasons. The health reform legislation
signed by President Obama on March 23, 2010, and the American Recovery and
Reinvestment Act of 2009 which proceeded it, include a range of initiatives that
seek to redesign the organization, financing, and delivery of health care. A num-
ber of these programs—for example, primary care medical homes and account-
able care organizations (ACOs)—rely on interventions that fall squarely within
the scope of practice of RNs (e.g., care coordination, transitional care). Further-
more, expanding the reach of insurance coverage will place greater demands on
the primary care system, as witnessed in Massachusetts (Long, 2008; Long and
1 The responsibility for the content of this article rests with the authors and does not necessarily
represent the views of the Institute of Medicine or its committees and convening bodies.
3

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3 THE FUTURE OF NURSING
Masi, 2009), and consequently on RNs and nurse practitioners to practice in these
settings (Craven and Ober, 2009). In addition, investment in the expansion of in-
teroperable health information technology (HIT) platforms that are critical to the
implementation of these system reforms will spur the growth of community-wide
information exchange that has the potential to change the distribution, skill-mix,
and scope of practice of nurses in profound ways.
So what does a reformed health care delivery system foretell for the future
nursing workforce? Will the demand for services provided by RNs change, as
the provisions in the legislation suggest, and if so is the nursing workforce po-
sitioned to effectively respond? What role will the nursing workforce play in a
post-reform environment? This paper examines these questions. We assess the
composition, skill set, and scope of practice needed from a future RN workforce
to support the health care delivery and coverage reforms that will emerge from
the reform legislation and related initiatives. We describe the future demand for
RNs under these reforms, how that demand comports with the current and an-
ticipated future supply of RNs, the challenges in meeting the workforce demands
of a reformed health care delivery system, and recommendations for future RN
workforce planning.
THE IMPACT OF HEALTH CARE DELIVERY REFORMS ON
DEMAND FOR HEALTH CARE SERVICES OF NURSES
What will be the demand for the health care services of RNs under the
proposed health care delivery reforms? An examination of the health reform
legislation and other related policy initiatives reveals a number of programs and
provisions that call for reorganization of health care services and the workforce
responsible for delivering them. Their implementation could have a significant
effect on the future roles of and requirements for RNs.
Advancing Care Management Models
“Care management” comprises a broad and evolving range of strate-
gies to effectively intervene and improve the care for primarily chronically ill
individuals—those whose care spans multiple providers and requires continu -
ous, long-term management. Disease management (DM) programs—diagnosis-
specific programs targeting chronic illnesses responsible for the largest share of
health care spending—have been the dominant form of care management pro-
grams for the past 15 years. DM programs target patients with specific chronic
illnesses (e.g., heart failure, chronic obstructive pulmonary disease, diabetes),
offer providers tools to improve their clinical management, promote outreach and
support strategies to improve patient adherence to treatment plans, and provide
feedback systems to monitor patient outcomes (Krumholz et al., 2006). Out of
DM programs came case management and care coordination strategies that target
persons with multimorbidity chronic illnesses and complex care needs in addition

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APPENDIX F
to one or more significant chronic illnesses. These programs rely on rigorous care
coordination and well-managed interdisciplinary clinical management to achieve
quality outcomes (Anderson, 2005; Bodenheimer, 2008).
Provisions in the Medicare Prescription Drug Improvement Modernization
Act of 2003 launched a series of population-based care coordination pilot pro-
grams to test the applicability of these strategies for Medicare beneficiaries and to
assess the quality improvement outcomes and cost savings that could be achieved
(Anderson, 2005; Foote, 2003). The evaluations revealed that while these pro-
grams yielded a variety of important quality outcomes, cost savings remained
largely elusive (Ayanian, 2009; Peikes et al., 2009). These findings echoed those
in an earlier report from the Congressional Budget Office for the U.S. Senate
Budget Committee that noted the promise but lack of evidence of cost savings
from these programs (CBO, 2004).
Further analyses, however, revealed that cost savings—principally by reduc-
ing avoidable hospital admissions—in addition to quality outcomes have been
achieved by some care management programs (Bodenheimer and Berry-Millett,
2009; Bott et al., 2009; Sochalski et al., 2009). Programs that have been suc-
cessful share several important features: care management strategies directed by
nurses who were integral to the physician’s practice, who coordinated care and
communication between the patient and all members of the interdisciplinary team
serving the patient, and who directly provided health care services via in-person
and telephonic/electronic methods. Increasing evidence is showing that enhanced
and integral involvement of nurses in both the coordination and delivery of care,
particularly for patients enduring multiple chronic illnesses and complex care
regimens, and in care management is critical to achieving cost and quality targets
(Fisher et al., 2009).
Several programs and initiatives included in the health reform legislation
involve interdisciplinary and cross-setting care coordination and care manage-
ment services of RNs.
Patient-Centered Medical Homes (PCMH)
Health reform raised the profile of strategies seeking to eliminate fragmenta-
tion in care and its costly and poor quality consequences. A recent report from
the Institute of Medicine’s Roundtable on Evidence-Based Medicine (2009)
estimated potential annual savings of $271 billion that could accrue by 2014 by
facilitating care coordination which would reduce these discontinuities in care.
One such strategy is the patient-centered medical home, an enhanced model of
primary care through which care teams attend to the multifaceted needs of pa-
tients and provide whole person comprehensive and coordinated patient-centered
care (Kaye and Takach, 2009).
Health reform’s version of the PCMH is an outgrowth of both structural and
care delivery innovations over the past several decades. The structure derives
from the pediatric medical home model developed to mainstream care for special

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needs children, and expanded to embrace the consensus view of primary care as
first-contact, comprehensive, continuous, coordinated care for all populations
(IOM, 1996; Starfield and Shi, 2004). This model is joined by key elements of
Wagner’s Chronic Care Model (Wagner et al., 1996), several system redesign
features (e.g., interdisciplinary collaboration and fully integrated HIT), and a
new payment structure that recognizes the broad set of services comprising the
patient-centered medical home (Berenson et al., 2008). The PCMH is intended
to address critical deficiencies in the current primary care system: (1) making
the “patient” the focus of and place for care—redesigning practice so that it is
truly “centered” on patient and caregivers; (2) meeting the growing challenge of
managing chronic illnesses in primary care settings; and (3) providing necessary
resources and payment for care management and coordination activities required
for an effective PCMH (Berenson et al., 2008; Chokshi, 2009; Rittenhouse et
al., 2009).
A fully functional PCMH is founded on patient and caregiver engagement
in care that meets patient preferences; information and education that promotes
self-management; care coordination that monitors, reviews, and follows up on all
services needed and provided across settings; secure transitions across health care
settings; and effective information flow across all providers and services to assure
integrated care delivery (Davis et al., 2005; Gerteis et al., 1993). This PCMH
model is envisioned to result in lower costs through reductions in emergency
room visits and hospital admissions (Hussey et al., 2009; Eibner et al., 2009).
Patient self-management, care coordination, and transitional care—services at the
core of the PCMH and shown to result in lower hospital and ER use—are directed
and provided by nurses.
The Guided Care Program offers an example of a successful PCMH model,
one that has improved patient outcomes and quality and reduced health care costs
through nursing services (Boult et al., 2008; Boyd et al., 2007, 2008; Leff et al.,
2009; Sylvia et al., 2008). The Guided Care (GC) model is a PCMH program
using an interdisciplinary team approach to coordinate care for older adults
with complex chronic conditions. Based in primary care physician practices,
GC nurses coordinate care among health care providers; complete standardized
comprehensive home assessments; and collaborate with physicians, patients, and
caregivers to create and execute evidence-based care guides and actions plans.
GC nurses work on a long-term basis with clients, provide transitional care, and
assist patients with self-management skills and accessing necessary community-
based services (Boult et al., 2008). Early findings from a cluster randomized
trial of this program reveal a 24 percent reduction in inpatient days, 15 percent
reduction emergency room visits, and a net Medicare savings of $75,000 per GC
nurse in the programs (Leff et al., 2009).
The Intermountain Healthcare Medical Group in Utah (Dorr et al., 2008) and
the Geriatric Resources for Assessment and Care for Elders (GRACE) program
in Indiana (Counsell et al., 2007) are PCMH models that have targeted high risk
older adults for rigorously coordinated care provided by nurses embedded in

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APPENDIX F
primary care practices, in the case of Intermountain, and nurse practitioner/social
worker teams in the case of the GRACE program. Each have achieved a signifi-
cant reduction of hospitalizations and lower costs. Similar gains were also found
for high-risk children in PCMH programs. Community Care of North Carolina
(McCarthy and Mueller, 2009; Steiner et al., 2008) had nurses provide case
management and care coordination services to high-risk Medicaid and SCHIP
enrollees, resulting in a 40 percent reduction in hospitalizations for asthma and a
16 percent reduction in emergency room visits and yielding total annual savings
of $154−170 million.
The Tax Relief and Health Care Act of 2006 directed the Centers for Medi-
care and Medicaid Services (CMS) to undertake a demonstration program to
test the effectiveness of PCMH models for Medicare enrollees and the capacity
to achieve both quality outcomes and lower health care spending through such
approaches to organize primary care. Provisions in the health reform legislation
complement Medicare’s demonstration program, testing different PCMH models
and creating a new CMS Innovation Center to support testing new approaches to
organizing, delivering and paying for health care services (Chokshi, 2009). Their
capacity to achieve real savings, some argue, will depend on the breadth of pro-
viders (e.g., primary care, specialists, hospitals) linked to the medical home and
the depth of interdisciplinary collaboration and care coordination among them
(Fisher, 2008), underscoring the focal role that nursing will play in achieving
these outcomes.
Transitional Care
Other innovations in care management also call upon the scope of practice
of RNs. Various current and proposed reforms would financially penalize hospi-
tals whose Medicare readmission rates exceeded an established threshold. These
provisions come on the heels of a recent study which found that one in five
hospitalized Medicare beneficiaries are readmitted within 30 days of discharge,
nearly half of whom return without having seen a physician or other health care
practitioner in the intervening period (Jencks et al., 2009). Of the $103 billion
spent by Medicare on hospital care in the study year, 17 percent was spent on
readmissions that were unplanned and potentially avoidable. These findings raise
serious questions about the coordination of care and hospital discharge protocols
in place where these patients sought care (Epstein, 2009). The financial penalty
is intended to serve as a significant incentive to hospitals to adopt evidence-based
strategies that will reduce avoidable readmissions.
Co-incident with the release of the readmission study, CMS announced the
14 sites for its newly funded Care Transitions Project. This nationwide pilot
program supports partnerships between Medicare’s Quality Improvement Organi-
zations and local providers to develop and implement strategies to manage the
transitions of Medicare patients from acute care to post-acute care settings,
whether it’s the patient’s home or another health care setting. Transitions between

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settings—e.g., hospital to home, hospital to nursing home—are points of great
vulnerability for patients, and poorly managed transitions are a chief culprit in
hospital readmissions (Coleman et al., 2006; Naylor et al., 1999, 2004). Two
prominent evidence-based models of care for managing transitions between set-
tings are founded on nursing services: Coleman’s Care Transitions Model and
Naylor’s Transitional Care Model. The Coleman model employs advanced prac-
tice nurses as “transition coaches” to manage chronically ill patients and their
care needs as they transition between settings and to encourage these patients and
their caregivers to assume more active roles in managing their care. The Naylor
model targets complex chronically ill patients—those with multiple chronic ill-
nesses and other complicating conditions—and uses specially trained transitional
care nurses to provide, manage, and coordinate the full complement of clinical
care and transitional care services during, between, and after the hospital stay.
Both the Coleman and Naylor models have demonstrated significant reductions
in hospital readmissions and health care costs. The health reform legislation
includes provisions for a startup program of transitional care that is modeled
directly on these two evidence-based models.
Accountable Care Organizations (ACOs)
ACOs received noteworthy attention within influential legislative circles
during the debate on health reform that led to their inclusion in the final legisla-
tion as a pilot program. ACOs, modeled in large part after successful integrated
delivery systems like Kaiser Permanente and Geisinger Health System, have been
advanced by the Dartmouth Institute for Health Policy and Clinical Practice and
Engelberg Center for Health Reform at the Brookings Institution. Their structure
grew out of the seminal work on the geographic patterns of health care use and
spending from the Dartmouth Institute (Fisher et al., 2009; Goldsmith, 2009;
McKethan and McClellan, 2009). Taking advantage of the natural clustering of
health care services around hospitals which the analyses on regional patterns of
service use revealed, ACOs are envisioned as locally integrated groups of hos-
pitals, physicians, and other providers that are responsible for the health service
needs of a defined population of patients (Crosson, 2009a). Their structure draws
from the current Medicare Physician Group Practice demonstration program and
the prior decade’s Physician Hospital Organization program (Crosson, 2009b).
ACOs offer a pathway to cost control through payment reform, by establish-
ing collaborations of providers that enter agreements with payers to be financially
accountable for the provision of health care services to a defined population.
These provider collaborations can take a variety of configurations to accommo-
date and build upon existing local relationships among providers. The payment
methods that have been proposed embody a variety of provider incentives to
meet cost targets including shared savings, shared risk, partial capitation, and
beneficiary incentives such as differential co-pays. Performance measurement

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APPENDIX F
is an integral component of ACOs to provide quality and cost benchmarks and
progress, and to ensure that cost control is not achieved through by limiting nec-
essary or appropriate care.
ACOs will depend on several structural and organizational features in order
to meet their cost and quality targets. Fully integrated electronic health records
(EHRs) and other types of HIT would be required for timely and meaningful
information sharing across the entire range of providers. Regular feedback on
performance and benchmarks will need to be shared with all providers, services
and enrollees in the ACOs. Moreover, ACOs will be supported and strengthened
by adopting rigorous, evidence-based care management practices that are the
foundation of many complementary system reforms, e.g., PCMHs and transi-
tional care, to manage and guide the care of fully functioning teams of providers
and to coordinate communication within and across teams, organizations, and
disciplinary lines.
The care management and coordination strategies adopted by ACOs and
other types of integrated delivery systems require an RN workforce that is linked
to the patient, can readily transition with the patient across time and care settings
and is ultimately accountable for outcomes that transcend time and place. RNs
working in this context would be employed by the ACO, one of its practices or
contracting care coordination organizations and would be responsible for care
management for the most complexly ill patients in the group and for their care
transitions. These transitions would include from hospital to home or other post-
acute setting, from home to hospital, or from ongoing primary care to intensive
outpatient secondary care.
Expanding Primary Care Capacity
The demand to build the primary care nursing workforce—both RNs and ad-
vanced practice nurses—will grow as accessibility to coverage, service settings,
and services increases. The Massachusetts experience provides evidence of this
growth in demand: passage of health reform in 2006 led to a substantial increase
in demand for primary care services only some of which could be met with the
existing reservoir of primary care resources (Long, 2008; Long and Masi, 2009).
Moreover, today the number of nurse practitioners (NPs) and physician assistants
(PAs) rivals the number of family physicians delivering primary care; thus a sub-
stantial share of the growth in demand for primary care services that will follow
the expansion in health coverage will by design fall on the shoulders of nurses
(Green et al., 2004).
The growth in health centers during the prior decade provides some param-
eters for quantifying the growth in the demand for the primary care RN work-
force. Between 2000 and 2006 the number of patients served by the nation’s
health centers grew 67 percent, to 16 million. To meet the concomitant increase in
demand for care, the number of primary care physicians at health centers grew by

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32 THE FUTURE OF NURSING
57 percent, advanced practice clinicians (i.e., NPs, PAs, and certified nurse mid -
wives [CNMs]) by 64 percent, and RNs by 38 percent. Yet despite that growth,
according to the National Association for Community Health Centers (NACHC
et al., 2008), health centers fell short by 1,843 primary care providers, including
physicians, NPs, PAs, and CNMs, and by 1,384 RNs.
NACHC estimates that 56 million people lack access to a primary care
medical provider (NACHC, 2007). For health centers to increase the number of
patients served (for medical visits) from 16 million to 30 million, an additional
15,600 to 19,400 primary care providers are estimated to be needed. Using the
current skill mix of clinicians, 36 percent of these additional providers—from
5,600 to 7,000—would be NPs/CNMs/PAs. In addition, health centers would
require another 11,600–14,400 RNs. Assuming that 75 percent of the advanced
practice clinicians would be NPs or CNMs, an additional 16,000−20,000 RNs
would be required to meet this demand.
National statistics on the RN workforce in primary care suggest that nursing
is not growing to meet this demand (Box F-1). The percent of RNs employed
in ambulatory care, e.g., clinics, physicians’ offices, health centers remained
virtually unchanged between 2004 and 2008, at just over 12 percent. This seem-
ingly steady employment rate masks the gradual decline in the ambulatory care
nursing workforce in a number of states. For example, the RN ambulatory care
workforce in Florida grew an appreciably decelerating rate over this period: 25
percent from 2004–2006, 12 percent from 2006−2008, and virtually no change
from 2008−2009. In 2007 ambulatory care settings employed 7.8 percent of RNs
in Pennsylvania, down from 8.4 percent 2 years earlier. In 2006 6.3 percent of
RNs in California worked in ambulatory care, down from 8.3 percent only 2
years earlier (UCSF School of Nursing and CHWS, 2007). Statistics from the
2004 National Sample Survey of Registered Nurses indicate that between 17,000
and 20,000 RNs were working in health center settings. Meeting the demand for
primary care services at community health centers estimated by NACHC would
require a doubling of the RN workforce in health centers today, an unlikely cir-
cumstance given the prevailing trends in ambulatory care employment of RNs.
Furthermore, community health centers represent only one primary care setting
that will demand additional RNs. Other services and settings offering access to
primary care and preventive health services and receiving enhanced support from
the health reform legislation and consequently will place additional demand on
RNs include workplace wellness programs, home-based primary care (e.g., In-
dependence at Home program), nurse home visitation services, nurse-managed
health centers, and community health teams.
Adoption of Health Care Support Technologies
Within the first few months in office President Obama signed economic
stimulus legislation that included a significant investment to expand the HIT

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34 THE FUTURE OF NURSING
infrastructure for the nation (Blumenthal, 2009). This investment is intended
to nourish the seeds of digital health care that are well rooted though not wide-
spread. Today only 15−20 percent of hospital RNs practice within a minimally
functional HIT infrastructure and well under 5 percent practice within a fully
wired context (DesRoches et al., 2008). However, a full array of HIT is expected
to diffuse rapidly over the coming decade, with significant implications for future
training, staffing models, and workforce policies for RNs. HIT is anticipated to
lead to (1) profound changes in the content and process of clinical practice; (2) a
redesign of the roles and skill mix of the health care workforce and the ways in
which multidisciplinary teams will work with one another; (3) new paradigms
for how time and place will influence the delivery of care; and (4) increased care
efficiency and better outcomes.
Changing Clinical Practice
HIT will fundamentally change the ways that RNs plan, deliver, document,
and review clinical care. The process of obtaining and reviewing diagnostic infor-
mation, making clinical decisions, communicating with patients and families, and
carrying out clinical interventions will radically depart from how these activities
occur today. Moreover, the relative proportion of time RNs spend on various
tasks is likely to change appreciably over the coming decades. While arguably
HIT will have its greatest influence over how RNs plan and document their care,
all facets of care will be mediated increasingly by digital workflow, computerized
knowledge management, and decision support.
In the future virtually every facet of nursing practice in each setting where
it is rendered will have a significant digital dimension around a core electronic
health record. Biometric data collection will increasingly be automated, and di-
agnostic tests, medications and some therapies will be computer generated, man-
aged and delivered with computer support. Patient histories and examination data
will increasing be collected by devices that interface directly with the patient and
automatically stream into the EHR. Automated blood pressure cuffs, PDA-based
functional status, and patient history surveys are examples of this.
In HIT supported organizations a broader array and higher proportion of
services of all types will be provided within the context of computer templates
and workflows. Care and its documentation will less frequently be “free-hand.”
As routine aspects of care become digitally mediated and increasingly rote, RNs
and other clinicians can be expected to shift and expand their focus to more
complex and nuanced “high touch” tasks that these technologies can not readily
or appropriately accomplish. This would include communication, guidance and
support of the patient/consumer and their families. There will likely be greater
opportunity for interventions such as counseling, behavior change, and social
and emotional support—interventions that lie squarely within the province of
nursing practice.

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APPENDIX F
Redesigned Roles and Skill-Mix
The new practice milieu—where much of nursing and medical care is me-
diated and supported within an interoperable “digital commons”—will support
and potentially even require a much more effective integration of multiple dis-
ciplines into a collaborative team focused on the patient’s unique set of needs.
Furthermore, interoperable EHRs linked with personal health records and shared
support systems will influence how these teams work and share clinical activities.
It will increasingly be possible for providers to work on digitally linked teams
who will collaborate with patients and their families no longer limited by “real-
time” contact.
As the knowledge base and decision pathways that previously resided primar-
ily in the clinicians’ brain are transferred to “clinical decision support” (CDSS)
and computerized provider order entry (CPOE) modules of advanced HIT sys-
tems, some types of care most commonly provided by nurses can readily shift to
personnel with less training or to the patient and their families. Similarly, many
types of care previously provided by physicians and other highly trained person-
nel can be effectively provided by advanced practice and other specialty trained
RNs. Furthermore, the performance of these fundamentally restructured teams
will be monitored through the use of biometric, psychometric, and other types of
process and outcomes “e-indicators” extracted from the HIT infrastructure.
Change in Time and Place of Care
Care supported by interoperable digital networks will shift in the importance
of time and place. The patient/consumer will need not always be in the same loca-
tion as the provider and the provider need not always interact with the patient in
real time. As EHRs, CPOE systems, labs results, imaging systems, and pharma-
cies are all linked into the same network, many types of care can be provided
without regard to location, as the “care grid” is available anywhere, anytime.
Remote patient monitoring is expanding exponentially. There is an ever-
growing array of biometric devices (e.g., indwelling heart or blood sugar moni-
tors) that can collect, monitor, and report information from the patient in real
time, either in an institution or the home. Some of these devices can also provide
direct digitally mediated care—the automated insulin pump and implantable
defibrillators are two extreme examples.
The implications of this for nursing will be considerable and as of yet not
fully understood (Abbott and Coenen, 2008). It is not clear how much of nursing
care might be “geographically untethered” when HIT is fully implemented but it
will likely be a significant subset of care, possibly in the range of 15−35 percent
of what nurses do today. In words, for this proportion of care, nurses need not be
in the same locale (or even the same nation) as their patients. As new technolo-

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are few integrated delivery systems or ACO-type entities that are responsible for,
and explicitly rewarded for, their overall performance across the settings that
comprise their system of care rather than a single setting. In the main, financial
performance is captured and rewarded at the level of the individual setting (e.g.,
hospitals) and not at the system level (e.g., ACO), so the behavior of each set-
ting is independent and driven by its own goals. Consequently, hospitals lack
the financial incentive to hire and deploy RNs to provide transitional care if the
outcome is reduced income in the form of reduced admissions. ACO-type orga-
nizations lack the incentive to employ RNs to provide care coordination and team
management services if these entities are not rewarded for improved financial
performance and quality outcomes that these services produce.
The second challenge lies in the educational sector. As currently designed
primary nursing education prepares nurses to function in discrete settings rather
than across settings (Benner et al., 2009) and as individual clinical provid-
ers rather than team members. Team-based care and care coordination are not
meaningfully integrated in primary nursing educational pedagogies. Reorienting
nursing education to incorporate these themes will require significant redesign of
both classroom and clinical education. Furthermore, primary nursing education
is still largely focused on the acute care setting. Preparing RNs, in addition to
advanced practice clinicians, to practice in ambulatory care settings where the
demand for care is clearly growing will require a substantial shift in classroom
education but even a greater shift in the clinical practica for students. Finally, the
scope and breadth of nursing education needed to meet the needs of reformed
health care delivery will require assessment of whether the current educational
modality—where the majority of nurses complete their primary nursing education
in associate degree programs—produces the right mix of RNs and skills needed
to enact these reforms. Without a change in demand, however, the educational
system will continue to produce the RN supply—the numbers and skill composi-
tion—that it has in the past.
Finally, workforce planning and forecasting will likewise require a com-
parable paradigm shift. Forecasting models based on current RN demand will
not produce useful estimates to guide future policy, i.e., the capacity of the RN
workforce to meet the needs of future models of health care services. The current
RN workforce is deficient in a number of dimensions to support health reform.
Specifically, there is a shortage of RNs deployed to ambulatory care settings and
a shortage of advanced practice nurses delivering primary care services. There is
a shortage of RNs trained and working as care managers directing and delivering
care coordination for patients in acute and post-acute care systems. There is a
shortage of RNs with sufficient training and experience in the full array of clini-
cal practice and team management skills that reorganized care delivery models
will require. Estimating these shortages, and developing the pathway to resolving
them argues for a wholesale new approach to assessing future nursing require-
ments and preparing and allocating nursing resources to meet those requirements.

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APPENDIX F
Moreover, without a national, integrated approach to workforce planning, one
that includes and obligates the critical stakeholders to the goals of an evidence-
based and effectively deployed health care workforce, forecasting efforts will
produce estimates that cannot guide future workforce planning. In the absence
of interdisciplinary collaboration, health care education and the supply forecasts
it feeds will proceed as a decentralized, professionally governed activity that
produces estimates of health care workforce requirements that meet individual
professional goals that may not serve the nation’s need for an effectively prepared
and deployed workforce.
Further challenging these efforts will be incorporating the effects of fully
integrated health information support, which available evidence suggests will
significantly influence the skill mix needed to deliver health care services. HIT
will be a key factor affecting the practice of nursing and medicine over the next
generation, and its impact on nursing practice and workforce requirements is still
very poorly understood. In the future, a more complex calculus will be needed
to assess the overall change in efficiency or cost versus benefit of HIT systems.
It will be necessary to provide controlled evidence showing the impact of an
entire well calibrated HIT supported system within an ACO or other integrated
delivery systems. Rather than a single end point (like RN time spent charting) a
full market basket of patient outcomes will need to be included as the end point
in this equation. And this assessment would also need to account for the fact that
the ACO will likely be able to adjust the skill mix of its HIT-supported workforce
in order to deliver the same or higher level of care quality more efficiently. For
example, this could be accomplished by substituting a higher percentage of lower
salaried professionals who can extend their scope of practice with guidance from
computerized clinical support systems.
Recommendations
Recommendation 1: The U.S. Department of Health and
Human Services should spearhead an interagency innova-
tions research collaborative with responsibility to test new
models for organizing health care services and determine
the workforce features critical to achieving desired cost and
quality outcomes.
For too long health services research and health workforce studies have
not been effectively integrated. Studies testing various models for redesigning
health care service delivery have focused primarily on the outcomes achieved
by delivery system innovations in contrast to usual care but have not included
an explicit assessment of the relative contributions of different configurations
and skill sets of health care clinicians to the outcomes achieved. Health care
workforce research has largely adopted a human capital approach—i.e., stud-

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ies assessing supply and demand for various health care clinicians and factors
contributing to recruitment and retention of health care workers—with little time
spent on assessing the optimal mix of clinicians and skills to achieve cost and
quality outcomes. By failing to integrate these two analytic areas, we produce a
health care workforce that is poorly positioned to efficiently and effectively enact
delivery system reforms that stand to improve system performance and costs.
Demonstration projects that assess the effects of service delivery innovations
and encourage a range of skill mix models as well as role differentiation (i.e.,
who performs which tasks) will grow the evidence base that is sorely needed to
inform both health system redesign and workforce planning. Only a concerted
and cumulative effort will produce the evidence needed to guide payment policy
changes that support delivery system and workforce reforms.
The U.S. Department of Health and Human Services should establish a
government-wide interagency innovations research collaborative comprising all
agencies/departments engaged in health care service delivery and research, with
the goal of testing new models to organize and pay for health care services and
determining the workforce features critical to achieving desired cost and quality
outcomes from these new models. The Quality Interagency Coordination Task
Force (QuIC), established in 1998 harness the federal government’s efforts in
health care quality improvement, offers a prototype for such an initiative (AHRQ,
2001). The purpose of the QuIC was “to ensure that all Federal agencies involved
in purchasing, providing, studying, or regulating health care services worked in
a coordinated manner toward the common goal of improving quality care.” Our
proposed innovations research collaborative would span such agencies as the Vet-
erans Health Administration, the Department of Defense, the Agency for Health-
care Research and Quality, the National Institutes of Health, and CMS. The new
Center for Medicare and Medicaid Innovation established under health reform
would be an integral participant. Dedicated funding from each agency would be
set aside to build the pool of funds available to undertake the concerted body of
research needed and increase the target populations and workforce configurations
studied to further our understanding of how to most effectively structure these
innovations. Private-sector partnerships would be encouraged, especially with the
payer community, since an appropriately aligned payment policy is the linchpin
to adopting new models of care by providers and demanding the workforce
needed to enact them. Additional partnerships with organizations engaged in
quality and outcomes measurement, such as the National Quality Forum, should
likewise be pursued. An independent advisory board should be empanelled to
develop recommendations on the innovations research agenda to be pursued by
the collaborative.
In addition to determining the skill mix configuration that produces optimal
cost and quality outcomes, a full assessment of the methods and processes by
which those configurations are achieved will be needed. This assessment would
explicate the range of policy and strategic initiatives that could be pursued to

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APPENDIX F
promote such configurations. Such skill mix changes have been of great interest
to the UK National Health Services (NHS), who sponsored a systematic review of
the literature on the shifting roles of health care providers (Sibbald et al., 2004).
In that review, which focused to a considerable degree on nursing, the authors
offered a framework that captured the range of processes through which changes
in the roles, and thus the skill mix, of health care providers occur (Box F-2).
The authors further note certain administrative or policy changes, largely at the
interface between settings, that could likewise lead to shifts in roles and skill mix
of providers (Box F-2). Dubois and Singh (2009) note that achieving optimal
“skill mix” options requires taking a much more dynamic approach to workforce
utilization by exploring the full range of skill flexibility and skill development
that could lead to newly configured roles and more effectively deployed staff.
This process would involve identifying and confronting any institutional and
regulatory barriers to achieving the staff configurations needed to meet the cost
and quality outcomes of these delivery system innovations.
Recommendation 2: The Health Resources and Services
Administration of the U.S. Department of Health and Hu-
man Services should (a) create a multistakeholder National
Workforce Advisory Group responsible for developing op-
BOX F-2
Processes and Policy Initiatives Producing
Health Care Workforce Skill Mix Changes
Processes producing role changes that influence skill mix:
• Enhancement—Current role of provider is extended
• Substitution—Provider’s role expanded by exchanging tasks with another type
of provider
• Delegation—Tasks are moved up or down a “traditional” disciplinary ladder
• Innovation—New domain of practice is created by introducing a new type of
provider with a previously untapped scope of practice
Policy initiatives producing shifts in roles and skill mix:
• Transfer—Services previously provided in one setting (e.g., hospital) are
now provided in another setting (e.g., ambulatory care) by a different set of
providers
• Relocation—Changing the setting of service but not the providers (e.g., tran-
sitional care nurses providing transitional care services in the hospital and the
patient’s home)
• Liaison—Providers in one setting (e.g., mental health) collaborate with those
in another setting (e.g., primary care) to shift clinical roles to that setting

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tions for integrated, skill-based workforce requirements
models, and (b) collaborate with the Agency for Health-
care Research and Quality (AHRQ) to provide funding to
support the development of analytic approaches to assess
skills shortages rather than personnel shortages and for ar-
ticulating optimal skill-mix configurations to address those
skills shortages.
Over the years the federal government has invested considerable resources in
analytic efforts to estimate the future supply of and demand for doctors, nurses,
and a range of allied health workers. Together the estimates from these activities
have been used to estimate the shortfall or surplus in these health occupations.
These efforts are flawed in several significant ways that affect their utility for
future workforce planning. As discussed earlier the demand-based models are
founded on current patterns of demand which we have shown for nurses to poorly
conform to evidence-based models for effective nursing use. The supply-based
models derive from current patterns of producing nurses that are influenced in
part by current demand and by current patterns of education that are not well
aligned with the future RN workforce requirements to support delivery system
redesign. Finally, these models do not take into account the overlap in the skills
and abilities of RNs and other health occupations, e.g., doctors, as well as other
nursing personnel categories.
In its 2008 report, Out of Order, Out of Time, the Association of Academic
Health Centers (2008) calls for the creation of a national health workforce plan-
ning body to provide a coordinated approach to health workforce planning that
offers an integrated national strategic vision rather than decentralized multi-
stakeholder decision-making. This idea is echoed in provisions in the health
reform legislation calling for the creation of a National Health Care Workforce
Commission. Our proposed recommendation would support and augment the
work of this Commission in two ways: (1) by creating an Advisory Group re-
sponsible for developing a range of options for building integrated skill-based
workforce requirements models, and (2) by providing funding through AHRQ to
explore ways to assess and compare the outcomes of health care services offered
under a range of skill-mix configurations derived from these integrated require-
ments models. These strategies would be founded on a comprehensive review
of the literature and related resources illuminating the full range of workforce
configurations employed in the delivery of health care services and, where avail-
able, associated outcomes.
The reorganization of health care service delivery that will accompany many
of the innovations included in health reform has potentially profound implications
for RNs, whose broad scope of practice places them at the cross section of virtu-
ally all health care settings. Redefining roles and responsibilities of health team
members that such innovations will entail could significantly affect the skill mix

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APPENDIX F
of the team and of nursing in particular. For example, HIT or other technologi-
cal innovations may allow health care workers with less training to move into
expanded roles with efficiency gains while maintaining quality, e.g., lab techs
rather than nurses recording and monitoring biological responses to treatment
changes; simultaneously these innovations may lead to improved care by moving
clinicians into previously unmet clinical arenas, e.g., moving RNs into providing
care management. In both instances these role redefinitions—lab techs moving
into clinical lab monitoring from which nurses exit as they assume new roles in
care management—change the roles and skills mix of health team members in
significant ways.
This recommendation provides strategies to develop and evaluate a broad
range of workforce configurations and assess their implications for health care
workforce planning. Moreover, by shifting the focus from personnel shortages
to skill shortage we invite a wider and more diverse array of policy options
to meet the care delivery needs of the public with more effective skill-mix
configurations.
Recommendation 3: Nursing education must become a full
partner of health care system redesign through meaningful
participation in redesign initiatives, and revamping its edu-
cational enterprise to meet the needs of redesigned service
delivery.
Health care services redesign and the nursing education enterprise are not
well aligned, as noted in highlights from the recent Carnegie Foundation study
on nursing education:
A major finding from the study is that today’s nurses are undereducated for the de-
mands of practice. Previous researchers worried about the education-practice gap;
that is, the ability of practice settings to adopt and reflect what was being taught in
academic institutions. Now, according to the authors, the tables are turned: nurse
administrators worry about the practice-education gap, as it becomes harder for
nursing education to keep pace with the rapid changes driven by research and new
technologies. (Carnegie Foundation for the Advancement of Teaching, 2009)
Delivery system redesign initiatives included in health reform depend upon
a set of skills and experiences that nursing education has yet to incorporate de-
monstrably into its pedagogy. Primary nursing education is still largely located
in the acute care domain, with students mastering the care of the acute manifesta-
tions of chronic disease rather than care management of complex chronic illness.
Care coordination and management are not integral to the classroom and clinical
activities of nursing students, and yet it is a role that nurses can and have ably
assumed in delivery settings where such skills will be increasingly demanded.
Transitional care, which the evidence to date shows is a critical feature in pre-

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venting hospital readmissions and other adverse events, lies directly in the scope
of nursing practice. Yet clinical education does not afford the opportunity to
follow patients across health care settings. Thus transitional care, as well as all
other cross-setting models of care, are infrequently practiced and thus even less
frequently taught. Despite its increasing recognition as the foundation for effec-
tive care into the future, team-based care and multidisciplinary care management
remain if anything the province of classroom instruction and rarely connected to
the practice setting. Primary care and community-based approaches to care rep-
resent a minority share of the nursing curriculum even as the demand for these
services is predicted to grow. The consequence is the production of succeeding
generations of nurses that are not well positioned—in numbers and skills—to
meet the needs of a redesigned delivery system.
Meaningful collaboration between nursing education and health care delivery
redesign will encourage the alignment in their goals, which is critical to their
joint success. Opportunities to advance such collaboration, and mechanisms
for its support, should be actively sought. For example, Medicare-funded pilot
studies and demonstration programs testing programs that rely on nursing-led
interventions, such as ACOs or transitional care, should include representatives
from nursing education—its leadership as well as key stakeholders, such as the
regulatory bodies that determine the terms and scope of nursing education and
practice—in activities associated with the design, review, implementation, evalu-
ation, and dissemination of these initiatives. In similar form, health professions
schools testing models of interprofessional education and other models of team-
based care education should include representatives from the clinical directors
of medicine and nursing in health systems and other key stakeholders from the
clinical practice communities.
In reciprocal fashion, this collaboration should inform nursing education as
to where gaps exist in educational offerings and skills development to meet the
needs of a redesigned delivery system. Closing the gaps will involve thoughtful
appraisal of where and how to integrate these new areas of knowledge and clinical
experiences into the current curricular offerings. Faculty expertise will need to be
developed in a number of these care models. The premium on clinical placements
will require consideration of how simulation learning environments may augment
current clinical experiences. HRSA should empanel a Technical Advisory Group
whose purpose would be to make recommendations on the role and opportunities
for relevant agencies within the federal government to support the development of
new programmatic and curricular offerings to build this needed skill set, includ-
ing a full review of the grants and initiatives within Title VIII and other sources
of federal funding for nursing education. The report from the Technical Advisory
Group should include a discussion of the role of other critical stakeholders, e.g.,
state regulatory bodies, health care private foundations, professional associations,
etc., in better aligning health professions education with the unfolding reforms
from health care reform and related initiatives.

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